Physicians’ Attitudes Towards Copy and Pasting in Electronic Note Writing
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The ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians’ collective experience with the copy and paste function (CPF).
To determine physicians’ CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use.
Resident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system.
Responses on a self-administered survey.
A total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF.
Although recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required.
KEY WORDSmedical records system, computerized documentation/mt [methods] attitude of health personnel medical staff, hospital user-computer interface
The authors would like to thank Drs. Erika Abramson, Susan Bostwick, Joseph Cooke, and Charles Schleien. Dr. O’Donnell was funded through the Department of Public Health at Weill Cornell Medical College as a Fellow in Outcomes and Effectiveness Research. The authors of this study have no financial conflicts of interest to disclose.
This study was funded by Weill Cornell Medical College through support for Dr. O’Donnell as part of her fellowship in the Department of Public Health. There was no external funding for this study.
- 1.Walton RT, Harvey E, Dovey S, Freemantle N. Computerised advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev. 2001;CD002894.Google Scholar
- 2.Kohn LCJ, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Committee on Quality in America. Washington, DC: Institute of Medicine, National Academy Pr: 1999.Google Scholar
- 4.Hammond KW, Helbig ST, Benson CC, Brathwaite-Sketoe BM. Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annu Symp Proc. 2003;269–73.Google Scholar
- 19.Kozak LJ, DeFrances CJ, Hall MJ. National Hospital Discharge Survey: 2004 annual summary with detailed diagnosis and procedure data: National Center for Health Statistics: 2006.Google Scholar
- 20.Levit K, Ryan K, Elixhauser A, Stranges E, Kassed C, Coffey R. HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2005. Rockville, MD: Agency for Healthcare Research and Quality; 2007.Google Scholar
- 22.Merill CT, Elixhauser A. Hospitalization in the United States, 2002. Rockville, MD: Agency for Heathcare Research and Quality; 2005.Google Scholar
- 24.Connolly C. Cedars-Sinai doctors cling to pen and paper. Washington Post. March 21, 2005: A01.Google Scholar
- 26.Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? Jama. 1999;282:867–74.PubMedCrossRefGoogle Scholar
- 27.Reeves S, Zwarenstein M, Goldman J, et al. Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2008:CD002213.Google Scholar